Blog
Clinical Documentation for Telehealth Sessions
Guide to documenting telehealth therapy sessions. Covers legal requirements, consent, technology issues, modified MSE observations, and telehealth-specific best practices.
Clinical Supervision Notes for Associate Therapists: A Practical Checklist for Defensible Documentation
A step-by-step guide for supervisors and group practices to document associate therapist supervision clearly and consistently. Covers required elements, risk language, action plans, and quality controls for audit-ready records.
Colorado HB 1195 AI Therapy Law: What Therapists Need to Know Before August 2026
Colorado HB 1195 requires written client consent before AI may record or transcribe therapy sessions. Generation-based documentation tools are explicitly exempt as "supplementary support." Here is what Colorado therapists need to know before the expected August 2026 effective date.
Common Documentation Mistakes Therapists Make
Avoid these common clinical documentation mistakes. Learn what therapists get wrong in progress notes, assessments, and treatment plans — and how to fix each one.
Concurrent Documentation in Therapy: How to Write Notes During Sessions Without Breaking Rapport
A practical guide for therapists weighing whether to write notes during sessions or after. Covers the real benefits and risks of concurrent documentation, evidence-based strategies for doing it well, and how to introduce it to clients without damaging the therapeutic alliance.
How to Document Dialectical Behavior Therapy (DBT) Sessions
A practical guide for DBT therapists on how to document individual sessions, skills group, phone coaching contacts, and consultation team meetings. Covers diary card documentation, chain analysis, behavioral targets hierarchy, skills module tracking, and how to write progress notes that capture DBT-specific interventions without losing the nuance of the modality.
Digital vs Paper Documentation: Pros and Cons
An honest comparison of digital and paper documentation for licensed professionals. Covers security, efficiency, compliance, cost, and disaster recovery.
Documentation Dos and Don'ts for Licensed Professionals
Universal documentation rules for therapists, physicians, lawyers, social workers, and educators. What to include, what to avoid, and how to stay protected.
Documentation Guide for Pre-Licensed Therapists and Clinical Interns
A practical documentation guide for associate therapists, interns, and clinical residents. Covers required elements for supervised hours, common mistakes that jeopardize licensure, and how to build sustainable note-writing habits from day one.
GIRP Notes for Therapists: A Complete Writing Guide with Examples
Learn how to write GIRP notes for therapy sessions. Step-by-step guide covering each section (Goal, Intervention, Response, Plan) with examples, when to use GIRP vs SOAP or BIRP, and adaptations for CBT, DBT, and psychodynamic approaches.
The Golden Thread in Clinical Documentation: How to Connect Treatment Goals Across Sessions
What auditors, supervisors, and insurance reviewers mean by "the golden thread" in therapy documentation, why it breaks, and practical techniques for maintaining longitudinal clinical coherence across every session note you write.
Golden Thread Documentation in Therapy: How to Connect Treatment Plans, Progress Notes, and Outcomes
A practical guide for therapists on building and maintaining the golden thread across the full episode of care: from intake assessment through treatment plan goals, session-by-session progress notes, and discharge summary. Includes SOAP and DAP format examples, guidance on updating goals without losing continuity, and a workflow for closing the loop at discharge.